Abstract
We performed this retrospective study to analyze our strategies for managing and surgically treating brachial artery injuries.
Fifty-seven patients with a total of 58 traumatic brachial artery injuries underwent surgery at our institution, from August 1996 through November 2004.
Fifty-four patients were male and 3 were female (age range, 7 to 75 years; mean, 29.4 years). Forty-four of the patients had penetrating injuries (18 had stab wounds; 16, window glass injuries; and 10, industrial accidents), 10 had blunt trauma injuries (traffic accidents), and 3 had gunshot injuries. Fourteen patients (24.6%) had peripheral nerve injury. All patients underwent Doppler ultrasonographic examination.
The repair of the 58 arterial injuries involved end-to-end anastomosis for 32 injuries (55.2%), reverse saphenous vein graft interpositional grafts for 18 (31%), and primary repair for 8 (13.8%). Venous continuity was achieved in 11 (84.6%) of 13 patients who had major venous injuries. Nine of the 57 patients (15.8%) required primary fasciotomy. Follow-up showed that 5 of the 14 patients with peripheral nerve injury had apparent disabilities due to nerve injury. One patient underwent amputation. There were no deaths.
We believe that good results can be achieved in patients with brachial artery injuries by use of careful physical examination, Doppler ultrasonography, and restoration of viability with vascular repair and dbridement of nonviable tissues. Traumatic neurologic injury frequently leads to disability of the extremities.
Key words: Brachial artery injury/complications/diagnosis/surgery, extremities/ blood supply/injuries, ischemia, peripheral nerves/ injuries, saphenous vein/ transplantation, thrombosis/ etiology, ultrasonography, vascular surgical procedures
Traumatic brachial artery injuries constitute a relatively large proportion of peripheral arterial injuries.1 In recent years, the limb salvage rate has reached nearly 100% because of early transport of patients to the hospital, early diagnosis, increased surgical experience, and developments in the treatment of hypovolemic shock and the use of antibiotic therapy.2–4
We report the results of a retrospective analysis of our strategies for the management and surgical treatment of traumatic brachial artery injuries.
Patients and Methods
Fifty-seven patients with a total of 58 traumatic brachial artery injuries underwent surgical repair procedures at our institution, from August 1996 through November 2004.
The brachial artery injuries were diagnosed by physical examination, Doppler ultrasonography, and arteriography. The following findings were considered to be signs of arterial injury: active bleeding, rapidly growing and pulsatile hematoma, pale and cold extremities, absent or very weak distal pulses, associated neurologic deficits, and associated injuries to bony and soft tissues. Decreased Doppler arterial systolic pressures detected on Doppler ultrasonography were considered to be diagnostic for arterial injury. Angiography was performed when the arterial injuries would be difficult to expose surgically and when the presence of arterial injury was problematic to predict.
The indications for fasciotomy were palpably tense compartments, major vein ligation, hypovolemic shock, ischemia lasting more than 6 hours, and any motor or sensory deficits. Orthopedic reconstruction was performed after revascularization of the extremity.
Optimal débridement of injured soft tissues was performed, and then injured and bleeding arterial and venous structures were exposed. Heparin was administered intravenously for systemic anticoagulation before the vessels were occluded proximally and distally with nontraumatic vascular clamps. Fogarty balloon catheters were used routinely for thrombectomy of the distal and proximal segments before final restoration of arterial flow. Distal and proximal segments of the artery were flushed with 0.1% heparin solution to prevent fresh thrombus formation.
Systemic heparin anticoagulation was administered postoperatively to patients who had severe soft tissue injuries and had undergone venous repair with reverse autologous saphenous vein interposition grafts.
All patients were treated with tetanus antitoxin preoperatively. All patients were also given preoperative and postoperative antibiotic therapy to reduce the high risk of infection related to contamination of the penetrating injuries or the presence of foreign bodies in the wounds.
Statistical analysis was performed using the paired-samples t test to determine whether there was any statistically significant difference between preoperative and postoperative Doppler pressure indices.
Results
Fifty-four patients were male and 3 patients were female. They ranged in age from 7 to 75 years (mean, 29.4 years). Forty-four (77.2%) patients had penetrating injuries (18 stab wounds [31.6%], 16 window glass injuries [28.1%], and 10 industrial accidents [17.5%]), 10 (17.5%) patients had blunt trauma (from traffic accidents), and 3 (5.3%) had gunshot injuries. Fourteen (24.6%) of 57 patients were in hypovolemic hypotensive shock, and 34 (59.6%) were actively bleeding.
Physical examination and Doppler ultrasonography revealed the absence of arterial pulses in 51 patients (89.5%) and weak arterial pulses in 6 (10.5%) (Table I). For brachial artery injuries, the average brachial- brachial Doppler pressure index was 0.422 ± 0.044 (range, 0.25 to 0.50) preoperatively, and 0.872 ± 0.024 (range, 0.81 to 0.91) postoperatively (P <0.05). Eight patients (14%) underwent preoperative angiography in order to confirm the vascular injury.
Table I. Signs and Symptoms of Arterial Ischemia among 57 Patients with Traumatic Brachial Artery Injury
Repair of the 58 arterial injuries required end-to-end anastomosis for 32 (55.2%) of the injuries; reverse, autologous, saphenous-vein interposition grafts for 18 (31%); and primary repair for 8 (13.8%).
In 13 patients (22.8%), serious venous injuries were associated with arterial injuries. In 11 (84.6%) of these patients, venous continuity was restored with saphenous vein interposition grafts, end-to-end anastomosis, and primary repair. Two severely injured brachial veins were ligated.
Nine (15.8%) of the 57 patients had injuries to soft tissues and bony structures. Fractures occurred most frequently among patients with blunt trauma (4 of 10 patients); fractures were also detected in 1 of 3 patients with gunshot wounds and in 4 of 44 patients with penetrating injuries. Ten patients (17.5%) had tendinous injuries that were repaired perioperatively by orthopedic surgeons.
Nine (15.8%) of the 57 patients required primary fasciotomy of the forearm. All patients who underwent venous repair procedures or ligation experienced edema in the upper extremity. This edema decreased with elevation of the extremity and resolved in all patients during the follow-up period (approximately 10 to 30 days). Fourteen (24.6%) of 57 patients had peripheral nerve injury: 3 had injuries to the median and ulnar nerves, 6 had injuries to the median nerve alone, 4 had injuries to the ulnar nerve alone, and 1, who had suffered a gunshot wound, had injuries to the median and radial nerves above the elbow of the right arm and injuries to the median and ulnar nerves above the elbow of the left arm. This patient required amputation of the right arm just above the elbow, because tissue viability could not be preserved. Five (11.4%) of the 44 patients with penetrating trauma had nerve injuries that were treated perioperatively by neurosurgeons. The remaining 9 patients with nerve injury underwent electromyelography for evaluation of injuries and were followed up in neurosurgery and rehabilitation clinics. During the follow-up period, functional recovery was achieved in 9 (64.3%) of the 14 patients with nerve injury. In the other 5 patients, disability was clearly evident throughout follow-up.
Three patients experienced early postoperative thrombosis. In 2 of these patients, arterial reperfusion was achieved with thrombectomy.
One patient underwent delayed amputation. This patient had suffered a gunshot wound to the right arm with injuries to the brachial artery, the brachial vein, and the median and radial nerves above the elbow in association with a fracture of the humerus. She also had injuries to the left brachial artery, the brachial vein, and the median and ulnar nerves above the elbow, as well as fractures of the left radius and ulna due to a gunshot injury. A saphenous vein graft was interposed between the axillary and brachial arteries of the right arm, but this graft was occluded by thrombus. Thrombectomy was attempted but was unsuccessful. The right arm was amputated just above the elbow, because viability of the tissues could not be preserved. The arterial circulation of the left arm was restored by the imposition of a brachioradial, reverse, autologous saphenous-vein graft, but the injuries to the median and ulnar nerves resulted in motor and sensorial defects in the hand.
Two patients with gunshot injuries experienced wound infections, but these infections were resolved within 2 weeks by antibiotic therapy.
The mean hospitalization period was 8.4 days (range, 2–37 days). The hospitalization time was longer for the patients who underwent fasciotomy because of compartmental syndrome, venous repair, musculoskeletal injury, or nerve injury. The average follow-up period was 16 months (range, 6–24 months); follow-up visits were usually necessary for orthopedic or neurologic examinations.
Discussion
The morbidity and mortality rates associated with brachial artery injuries depend on the cause of the injury itself, which vein or tendon is injured, and whether musculoskeletal and nerve injuries are also present.
Patients with obvious clinical symptoms of brachial artery injuries as detected by physical examination and those in whom Doppler ultrasonography demonstrates a substantial difference in pressure between the right and left brachial arteries should undergo surgical repair without further angiographic examination. Doppler ultrasonography of the upper extremity has been shown to be as specific and sensitive as arteriography in detecting brachial artery injuries.2,5–7 Normally, the average brachial–brachial Doppler pressure index between the 2 upper extremities is approximately 0.95; it is rarely less than 0.85.8 In our patients, this measurement was significantly lower than normal preoperatively but was close to normal postoperatively (P <0.05). If uncertainty remains regarding vascular injuries after physical examination and Doppler ultrasonography, angiography may be used to confirm the vascular injury. Eight (14%) of our patients required preoperative angiography.
Six patients exhibited pulse insufficiency. The pulses of those patients were not palpable on manual examination but were detected on Doppler examination. Surgical exploration revealed partial injury to the brachial artery. These findings may be explained by collateral flow or by the flow bypassing the partially injured brachial artery.9
Because tissue maceration is widespread after gunshot wounds, and because these macerated tissues frequently become nonviable, the environment is ideal for bacterial infection. Therefore, tissue dbridement must be performed. After proximal and distal control of the bleeding artery has been achieved, the artery should be explored until the uninjured arterial wall is apparent. Both segments of the brachial artery can be mobilized by ligation of the immediate minor branches; this procedure provides additional length and reduces the tension at the anastomosis.
End-to-end anastomosis is preferable if it can be performed without tension or damage to major collateral vessels. Otherwise, the saphenous-vein interposition graft is the next best choice, because it has better patency rates and better resistance to infection compared with synthetic grafts.4
Although the rate of thrombosis associated with venous repair ranges from 39% to 59%, the injured major veins must be repaired so that arterial flow can be restored.10,11 We were able to restore venous continuity in 11 of 13 patients with major venous injuries.
Three patients had early postoperative thrombosis; arterial reperfusion was achieved in 2 of these patients by embolectomy. In the 3rd patient, who had suffered a gunshot injury and severe tissue destruction, embolectomy was unsuccessful and amputation was necessary.
Compartmental edema or contusion can impair venous drainage and arterial flow and can cause pressure injuries to the nerves.12,13 Nine (15.8%) of our patients underwent primary fasciotomy of the forearm, and 9 had bone fractures. In the patients with musculoskeletal injuries, arterial revascularization was performed before skeletal injury stabilization so that ischemia time could be kept to a minimum.
Neurologic injury continues to destroy the function of the upper extremity even after a successful arterial repair. Major venous injuries, fractures, and widespread tissue destruction may also influence the long-term function of the extremity.14 Whether primary and secondary nerve repair procedures are helpful is a point of controversy.15 The rate of functional disability ranges from 27% to 44% when injury to the upper extremity includes nerve injuries.16
In our series, the outcomes of our 14 (24.6%) patients with nerve injuries were similar to those of patients discussed in other reports.14,16 Five (35.7%) patients with nerve injury experienced severe, long-term disability. Those patients were followed up in neurosurgery and rehabilitation clinics.
During the last 20 years, amputation associated with upper extremity arterial injuries has decreased to a rate of 3.1% to 3.4% because of advances in the treatment of shock, the use of antibiotic therapy, and increased surgical experience.16 Only 1 of our patients required amputation. None of our patients died.
Conclusion
In an upper extremity that is severely endangered by ischemia, it is essential that arterial and major venous exploration and vascular repair be performed, in conjunction with débridement of damaged tissues, if viability is to be restored. Careful clinical examination, Doppler ultrasonography, and pressure measurements are as important as angiography in the diagnosis of vascular injuries. Traumatic neurologic injury may significantly affect the degree of long-term disability after upper extremity injuries.
Footnotes
Address for reprints: Kazim Ergunes, MD, 2040-1 Sokak, Selcuk-1 No:2, Daire 51, Mavisehir, 35540 Karsiyaka – Izmir, Turkey
E-mail: kazimergunes@yahoo.com
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